ARTICLE VI.

A DISSERTATION,

READ BEFORE THE

Massachusetts Medical Society

AT THEIR

ANNUAL MEETING, JUNE 6, 1827.

BY NATHANIEL MILLER, M.D.

GENTLEMEN,

I HAVE been much perplexed in selecting a subject of discussion for the present occasion. But anticipating that something in relation to Surgery might be expected, and always happy to gratify the wishes of this society, I have taken a branch of that noble art for a few practical and experimental remarks.

It is, however, very difficult to find a distinct topic, which has not been thoroughly investigated, described and treated with accuracy by the most eminent, scientific and practical surgeons. I have feared that it might be considered presumption for

one who has enjoyed only the comparatively few anatomical facilities which the interior affords, to attempt to throw any additional light upon subjects which have received the minute attention of so many learned and practical minds.

I had contemplated confining myself to some practical remarks upon the nice and beautiful operation for the cataract. This subject has been very minutely investigated by eminent men, who have endeavoured to point out the best method of restoring sight to the unfortunate sufferers from this complaint. Yet this very important branch of the surgical art is still enveloped in darkness and great uncertainty; and the young and inexperienced practitioner is left to adopt that mode, which his own discretion, or that of his capricious instructor, may dictate.

By one, we are informed that removing the opaque lens wholly from the eye, through the pupil, is the best method of relieving the difficulty. Another, with perhaps equal experience and sincerity, will tell you that pressing down the lens from its nidus is the better mode; whilst a third asserts, with unbounded confidence, that only poking and lacerating the sight of the eye is the most humane and successful-thus leaving this delicate organ, with the vague expectation, that the inherent powers of kind nature will lend their aid, to give success to the uncertain procedure.

I was formerly much engaged in the operation for Cataract. In May and June 1798, I operated on twenty-one eyes by extraction. All received sight, save one, in the course of three and six weeks. As far as our present knowledge extends, I am decidedly in favor of this mode of operating. I presume, however, that I should gain but few proselytes to my belief among those who have commenced practise, and made themselves familiar with other methods. The assurance which long experience has furnished me, might be imputed to my peculiar prejudices; and to that unfounded preference, which often arises from the long and exclusive practise of any particular method of treatment. therefore leave this subject of inquiry, being well assured that, at no distant period, a mode of operating, different from any now in use, will be the received one, embracing more the objects of the operation without its present difficulties; and that the result will be attended by less pain and far

more success.

I

The subsequent remarks will be confined to the principal objects of this discourse, viz. to illustrate the importance, and direct the manner of detecting deep seated matter.

As far as I have been acquainted with surgery, a knowledge of detecting deep seated matter, concealed in various parts of the body, whether in tumours, swellings, or otherwise, is of the first impor

tance; nay, the very first lesson to be taught, and understood, in our profession.

A great proportion of the strictly surgical cases presented to us, either for advice or treatment, involve, in fact, this question of matter; and a right understanding of this directs the prognosis and cure. A knowledge of this subject lays the foundation of a practice, which, in a multitude of instances, will alone guide you, in safety, to the restoration of your patient.

The labours of Benjamin Bell (more, perhaps, than those of any other man) have been the means of exploding many of the barbarous practices formerly in vogue in this country. Speaking, in his system of surgery, upon collections of matter, he says, "this is a circumstance of much importance in practice, and deserves, it may be remembered, more attention than is commonly given to it. In no part of a surgeon's employment, is experience in former similar cases, of more use to him than in the present; and however simple it may appear, yet nothing, it is certain, more readily distinguishes a man of observation and extensive practice, than his being able easily to detect deep seated matter. While nothing, on the contrary, so materially affects the character of a surgeon as his having, in such cases, given an inaccurate or unjust prognosis; for the event in disorders of this kind comes generally at last, to be clearly demonstrated to all con

cerned." Again he says, "abscesses too, on any of the joints, or upon either of the large cavities of the breast or abdomen, and more especially when they seem to run deep, should always be opened as soon as the least fluctuation of matter is discovered."

Baron Boyer, in his able Treatise on surgical diseases, strongly admonishes to a watchful attendance on abscesses, when they are near an organ, surrounded by a great quantity of cellular substance, as the lower extremity of the rectum. If we waited to open such an abscess, for a total solution of all the inflamed parts, the intestines would become denuded to a great extent, and their union with the adjoining parts would be difficult. By their pressure sometimes on the urethra they will cause a retention of the urine and death; in parts also which are immediately concerned in the natural functions of life as in the parotids, preventing a free return of blood from the head to the heart-on the anterior part of the neck preventing respiration and deglutition, &c.

I will now, Gentlemen, briefly mention the general symptoms, as they are laid down in our standard works, and the directions therein given for detecting matter; then close with a few critical remarks, and with directions on this subject.

The directions of the authorities for the discovery of matter may be summed up in these few words;